Acad Psychiatry (2014) 38:35–42 DOI 10.1007/s40596-013-0017-3
IN DEPTH ARTICLE: SYSTEMATIC REVIEW
Impact of the Psychiatry Clerkship on Medical Student Attitudes Towards Psychiatry and to Psychiatry as a Career Zaza Lyons
Received: 12 December 2012 / Accepted: 26 April 2013 / Published online: 24 January 2014 # Academic Psychiatry 2014
Abstract Objective The psychiatry clerkship forms part of the core curriculum of medical schools worldwide and provides psychiatric educators with an ideal opportunity to positively influence students. The aim of this paper is to systematically review literature on the impact of the psychiatry clerkship to determine the effect on attitudes towards psychiatry and to psychiatry as a career. Method A systematic review was undertaken. The following key search words were used to search a number of electronic databases: medical student/s, attitude/s, psychiatry and clerkship. Studies published in the English language from 1990 to the present were included. Studies were included if they were based on a pre-/post-design, i.e. the same students must have participated in the study both before and after the clerkship. Results Twenty-six studies from 19 countries were identified for the review. Sixteen studies reported an overall improvement in attitudes towards psychiatry post-clerkship, and ten found no change in attitudes. In terms of career choice, nine studies reported an increase in the number of students interested in psychiatry as a career post-clerkship, nine found no impact on career choice and, in eight studies, it was not assessed. A number of positive and negative factors regarding the clerkship were identified. Conclusion Overall, the psychiatry clerkship has a positive impact on students' attitudes towards psychiatry, but does not improve interest in psychiatry as a career option. For those students particularly interested in psychiatry, the challenge is to maintain their enthusiasm post-clerkship. Charismatic teachers, mentorship and stigma reduction may be effective
Z. Lyons (*) University of Western Australia, Crawley, WA, Australia e-mail: [email protected]
strategies. Future research needs to more clearly identify specific components of the clerkship that are viewed favorably by students. Keywords Medical student . Impact . Clerkship . Attitudes . Psychiatry Attitudes of medical students towards psychiatry have been extensively studied over the last three decades. A recently published review of 32 studies showed that, overall, students' views are generally more positive than negative; however, the proportion who choose psychiatry as a career remains low [1]. Psychiatry is now firmly embedded as part of the core curriculum in all medical courses [2]. A combination of different teaching techniques, including problem-based and didactic learning, and clinical clerkships is used to teach students the skills, attitudes and knowledge relevant to the discipline of psychiatry [2]. For students in the clinical years, clerkships provide a more realistic view of psychiatry than may have been gained through lectures and tutorial sessions during the pre-clinical years. These experiences can become important factors in later career decision making [3, 4]. Clerkships are usually between 4 and 8 weeks in length (average 6.3 weeks) [5] and, in most courses, are the only clinical exposure that students have of psychiatry. This provides a narrow window to ensure that the experience is positive and emphasis on ‘getting it right’ becomes imperative. The clerkship gives psychiatric educators an ideal opportunity to positively influence students, and while there is no doubt that the experience has an impact on attitudes, there is less clarity from the existing literature on the strength and direction of this change [6]. The aim of this systematic review is to determine the impact of the psychiatry clerkship on attitudes of medical
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students towards psychiatry and to psychiatry as a career choice. A more comprehensive viewpoint of the effectiveness of clerkships may enable psychiatric educators to use the clerkship effectively to ensure that it provides students with a beneficial learning experience and improves their attitude towards psychiatry and to psychiatry as a career choice. It should be noted that, for consistency in terminology, the word clerkship is used throughout this paper and is synonymous with rotation, attachment, posting and other similar terms that may be used as local equivalents.
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these articles to identify those meeting the selection criteria was undertaken by the author and resulted in the identification of 42 papers. In order to minimize selection bias, a senior colleague undertook a further independent assessment of these papers. They were then were read in full to determine suitability for inclusion in the review. Sixteen papers were excluded, leaving 26 that were finally selected. Papers were excluded if they were not based on a pre-/post-design; students were surveyed retrospectively; or pre/post measures were performed on different student cohorts.
Results Method Summary of Main Findings The method used was consistent with the previous systematic review undertaken by the author [1]. The following electronic databases were searched: MEDLINE, EMBASE, Web of Science, ScienceDirect, AustHealth (Informit), CINAHL Plus (Ebsco), Global Health (Ovid), Health and Medical Complete (Proquest) and PsychInfo. In addition, the reference lists of studies included in the review were hand searched. Finally, using the available online archive search functions, each available issue from key journals was hand-searched. These were Academic Psychiatry, Medical Education, Medical Teacher and Academic Teacher. Searches for personal communications and conference data were not undertaken. Search words used were medical student/s, attitude/s, psychiatry and clerkship. In order to include words synonymous with ‘clerkship’ the following terms were also acceptable: rotation, attachment, posting, affiliation, training programme and education. The following criteria were used to determine inclusion of papers for the review: (1) must have been published in an English language, peer reviewed journal from 1990 onwards; (2) all the search words to appear in the title and/or abstract; and (3) reporting primary research with medical students as respondents. Studies were included if they were based on a pre-/postdesign, i.e. the same students participated in the study both before and after clerkship. This was to ensure that only studies specifically assessing the impact of the clerkship were included. The previous review [1] focused on the cross-sectional assessment of students' attitudes towards psychiatry and did not include clerkship studies. The following information was extracted from each paper: year of publication, country where the study was conducted, aim/s, sample size and response rate, year of course in which the clerkship took place, length of clerkship and main results. A global ‘yes/no’ assessment to indicate if overall attitudes to psychiatry had improved post-clerkship was made. The electronic search identified 315 papers that had any one of the key search words in its title. An initial screening of
All 26 studies assessed the impact of the clerkship on student attitudes and were based on a pre-/post-design, where students were asked to complete questionnaires at the beginning and end of the clerkship. Eighteen studies also assessed the impact on career choice. A summary of each study including author, country where conducted, aims, year level surveyed, length of clerkship and overall improvement post-clerkship is shown in Table 1. Overall, 16 studies reported an improvement in attitudes towards psychiatry post-clerkship. The remaining ten concluded that the clerkship had not changed attitudes. In terms of career choice, nine studies reported an increase in the number of students interested in psychiatry as a career postclerkship, nine found no impact on career choice and, in eight studies, it was not assessed. The reviewed studies were conducted in 19 different countries. There were four from Nigeria, two each from Malaysia, UK, Israel and USA, and one study from each of the following countries: Australia, Sri Lanka, Portugal, Saudi Arabia, Pakistan, Oman, Germany, Denmark, Iran, Spain, Greece, Turkey, Ireland and Chile. Design of Studies Several different validated questionnaires were used to survey students. Eight studies [7, 8, 13, 17, 21, 24, 26, 29] used the ATP-30 [33], four [9, 10, 14, 23] used the Balon questionnaire [34], two [15, 19] the Nielsen and Eaton questionnaire [35] and two [31, 32] a questionnaire designed by Wilkinson [36]. One study [27] used the Libertarian Mental Health Scale [37] and one [16] a questionnaire by Das and Chandrasena [38]. The remaining eight developed their own questionnaires. A total of 3,747 students participated in completing baseline and follow-up questionnaires. One study used a control group of students doing an ophthalmology clerkship [28], and two assessed different courses resulting from recent curriculum changes [24, 26]. Two studies surveyed other year levels
To examine the impact of clerkship on attitudes to psychiatry and career. Year 5; 4 weeks To assess the effect of new clerkship on career choice and attitudes towards psychiatry. Final year students; 8 weeks To evaluate attitudes to psychiatry and as a career. New curriculum and clerkship model. Year 6; 4 weeks To understand changes in attitudes to psychiatry post clerkship. Year 5; 6 weeks To examine impact of clerkship on beliefs and attitudes towards mental illness. Final year students; 4 weeks To determine change in attitudes following clerkship. Year 4; 4 weeks To report impact of the clerkship on attitudes towards psychiatry. Final year students; 4 weeks To assess the impact of the clerkship on attitudes to psychiatry. Year level not stated; 6 weeks To assess the impact of the clerkship on attitudes to psychiatry of Israeli students and US students studying in Israel. Year level not stated; 5 weeks To explore attitudes and career intentions. Year level not stated; 8 weeks To assess students attitudes in 4 different semesters to psychiatry and determine if these change during medical school. Students in year 5 only surveyed pre and post clerkship. Length of clerkship not stated To assess change in attitudes after clerkship and impact on career. Years 4 and 5 at 3 universities; 4 weeks
2012, Adebowale et al., Nigeria [7]
2012, Rodrigo et al., Sri Lanka [8]
2010, Xavier. Portugal [9]
2010, El-Gilany et al., Saudi Arabia [10]
2010, Aghukwa, Nigeria [11]
2009, Sajid et al., Pakistan [12]
2009, Issa et al., Nigeria [13]
2008, Ramamurthy et al., Malaysia [14]
2008, Fischel, Israel [15]
2008, Al-Adawi et al., Oman [16]
2007, Kuhnigk et al., Germany [17]
To assess impact of clerkship on changes in attitudes and career. Year 5; 4 weeks To assess attitudes towards clerkship and various aspects of the curriculum and teaching. Year 3; 4 weeks To examine the impact of clerkship on attitudes to mental illness and psychiatry. Year 4; 8 weeks To examine attitudes to mental illness before and after clerkship. Year 3; 6 weeks To gain understanding of choosing psychiatry as a career and how attitudes change during academic year. Year 4; 6 weeks
2006, Samimi et al., Iran [19]
2006, Niedermier et al., US [20]
2005, Reddy et al., Malaysia [21]
2005, Galka et al., US [22]
2005, Bulbena et al., Spain [23]
2007,Holm-Petersen et al., Denmark [18]
Aims, year/s surveyed, length of clerkship
Year, author, country
Table 1 Summary of reviewed studies
100 % (48) pre and post
70 % (672) pre and post
Sem 10 students: 100 % (136) pre 93 % (127) post 73 % (223) pre 70 % (214) post 87 % (109) pre 87 % (109) post (184) pre (184) post RR not given 70 % (122) pre and post
83 % (171)
75 % (67) pre 53 % (47) post 100 % (126) pre 100 % (135) post 78 % (91) pre 76 % (89) post Israeli: (29); U.S. (28) RR not given
N =35 pre and post
96.4 % (54) pre and post
66.9 % (81) pre 88 % (106) post 91 % (91) pre 93 % (93) post 100 % (153) pre and post
Response rate, sample size
Attitudes—yes Career—yes Attitudes—yes Career—no Attitudes—yes Career—yes
Career—no
Attitudes—yes Career—yes Attitudes—yes Career—yes Attitudes—yes
Career—no Attitudes—no Career—no
Attitudes—yes Career—no Attitudes—no Career—yes Attitudes—no Career—N/A Attitudes—no Career—N/A Attitudes—yes
Attitudes—yes Career—no Attitudes—no Career—yes Attitudes–yes Career—yes Attitudes—yes Career—N/A Beliefs and attitudes—no Career—N/A
Overall improvement post-clerkship
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Aims, year/s surveyed, length of clerkship
To assess attitudes to psychiatry, career intentions and experiences during the clerkship. Year 4; 8 weeks. 2 cohorts—one traditional content, one PBL To evaluate impact of clerkship on beliefs and attitudes towards psychiatry. Year 5; 8 weeks To compare efficacy of new curriculum (vs old) of students attitudes to psychiatry and mental illness. Year 4; 8 weeks (old); 6 weeks (new) To compare attitudes of a previous sample (1985) of students with current students (1993) before and after clerkship. Year 4; 16 weeks (1 day/week) To compare attitudes to mental illness between students doing psychiatry clerkship with those doing ophthalmology clerkship. Year 5; 3 weeks To measure the impact of clerkship on attitudes. Final year students; 8 weeks To evaluate student attitudes before and after clerkship. Year 5; 5 weeks To assess changes in attitudes after clerkship. Final year students; 4 weeks To assess changes in attitudes after clerkship and determine if these change over time. Year 3 (no exposure); Year 5; 8 weeks; interns
Year, author, country
2003, McParland et al., UK [24]
2001, Oluto & Osahon, Nigeria [25]
1998, Singh & Baxter, UK [26]
1998, Garyfallos et al., Greece [27]
1997, Arkar & Eker, Turkey [28]
1996, Sloan et al., Ireland [29]
1996, Guttmann et al., Israel [30]
1995,Galletly et al., Australia [31]
1992, Arya et al., Chilie [32]
Table 1 (continued)
Year 3: 94 % (75) pre 100 % (80) post Year 5: 80 % (48) pre 90 % (54) post Interns: 85 % (56) pre 74 % (49) post
(153) pre and post RR not given
88 % (53) pre 72 % (43) post
(75) psyc group (60) opth group RR not given 95 % (110)—from 3 med colleges
90.3 % (140) 1993 (51) 1985
90 % (110) pre and post
(105) pre and post RR not given
84 % (379) pre and post
Response rate, sample size
Attitudes—yes Career—no
Attitudes—yes Career—yes Attitudes—no Career—N/A Attitudes—no Career—no
Attitudes—yes Career—yes Attitudes—no Career—no Attitudes—yes Career—N/A Attitudes—yes Career—N/A Attitudes—no Career—N/A
Overall improvement post-clerkship
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as well as the year group undertaking the clerkship as a means of determining changes in attitudes at different stages of training [17, 32]. Two studies surveyed students from more than one medical school [18, 29]. Response rates ranged from 100 to 50 %. The average length of clerkship was 5.5 weeks, range of 3– 16 weeks. In nine studies (35 %), it was 4 weeks; in seven studies (30 %), it was 8 weeks; in five studies (19 %), it was 6 weeks, two studies (8 %) had a 5 week clerkship; and two others (8 %) had 3 and 16 week clerkships, respectively (NB; students in this study spent only 1 day/week in a clinical setting). In one, the length of clerkship was not stated. It is not possible from the information provided to determine if the clerkship described in the study represented the only clinical exposure to psychiatry that students had, or if further clerkships occurred at different times. There was no identifiable trend between length of clerkship (shorter or longer) and improvement in attitudes or career choice.
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exposure with patient contact. Across studies, non-clinical content was mainly comprised of lectures [7, 10, 13–15, 19, 28, 29], tutorials, including PBL [10, 11, 14], seminars [7, 9, 22], theory lessons [9–11, 23, 27], diagnostic classification [13, 27], case presentations and histories [12, 15], journal club [12], history taking and interviewing skills [13, 29], formulation [29], small group discussions [10, 12], research project and self-directed learning activities [14]. For the clinical component, the most prominent features in all studies were exposure to adult inpatient wards and outpatient clinics. Other features included acute wards/emergency departments [8, 9, 23, 27], rehabilitation [9, 29], community liaison [8, 9, 13, 20], child and adolescent psychiatry [8, 9, 13, 20, 22, 23, 29], old age psychiatry [13], addiction medicine/ substance abuse [8, 13], forensic psychiatry [13, 29], centre for learning disabilities [29], psychotherapy [13], ward rounds [11, 29], experience of closed wards [15], electro convulsive treatment (ECT) [13, 20] and evening on call [20].
Impact of Clerkship on Attitudes and Career Choice Discussion Attitudes were often positive at the beginning of the clerkship and improved further post-clerkship. Inevitably, most studies reported a mix of views that improved, deteriorated or showed no change post-clerkship. Some studies found that students with more positive attitudes correlated with greater interest in psychiatry as a career and higher exam results. Female students showed greater improvement in attitudes post-clerkship than male students in four studies [7, 16, 21, 32]. Age was reported in less than half the studies reviewed, and overall, it was not possible to determine if it was a factor in postclerkship attitude change. An improvement in views postclerkship was found in the following areas: value and experience of psychiatric teaching [8–10, 17], effectiveness of treatment/consultation [8–10, 16, 21, 22], scientific basis of psychiatry [9], specialization of psychiatry and psychiatrists as professionals [9, 10, 16, 18, 23], causes/beliefs towards mental illness [11, 22] patients [12, 13, 18, 21], merits of psychiatry [14, 30], improvement in clinical skills and understanding patients feelings [30]. No change, or a deterioration in views, was reported in a number of important areas by some studies—attitudes towards mental illness and patients [11, 13, 25, 28], teaching of psychiatry [12, 23], psychiatry as a discipline and psychiatrists [13–15, 30], knowledge in psychiatry [15], merits of psychiatry [23], treatment/prognosis [23, 30] and the scientific basis of psychiatry [30]. Clerkship Structure Most studies provided some information about the structure of the clerkship. While this varied considerably between courses, all provided a mix of non-clinical teaching and clinical
Despite differences in both the length and structure of the clerkship between medical schools that make it difficult for direct comparisons to be made, of the 26 studies reviewed, 16 (61 %) showed that students' attitudes improved postclerkship. However, the impact on career choice was less positive, with only nine out of 18 studies that assessed career choice finding that the clerkship increased students' interest in psychiatry as a career. While the improvement in attitudes post-clerkship is positive, these effects decay as students' progress through the medical course and into internship [39–41]. Career preferences also fluctuate as students advance through the clinical years, as exposure to different areas of specialization and acquisition of new skills and knowledge enables them to assess their interest in each area and determine its suitability as a career [42]. Positive Clerkship Factors The basic structure of the clerkship combines lectures, tutorials and other non-clinical activities with the clinical attachment, usually based in hospitals and outpatient clinics. The experiences gained during the clinical component of the clerkship, however, are more likely to influence students' attitudes than the non-clinical teaching activities. Different settings (outpatient clinic, hospital based consultation liaison service, and acute inpatient ward) have been found to have little impact on eventual career choice, examination marks or psychiatric knowledge [43]. However, an outpatient clerkship may have a more positive effect on career choice [44]. Other factors that constitute a good clerkship experience have been identified as the quality of the clinical teaching, the organisation of the
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clerkship and its supervision and learning activities [45]. The opportunity to develop close personal relationships with patients, deal with challenging diagnoses and a diversity of clinical experiences are also influential aspects in specialty choice [46]. From a student's perspective, an important aspect of any clerkship is patient contact and the relationship with patients that develops during the clerkship [46]. Some studies have shown that students' attitudes towards patients improved post-clerkship, and patient contact was regarded as a rewarding aspect [12, 18, 20, 26]. Others, however, have not shown improvement [13, 28] and patient behaviour, particularly in acute inpatient settings, has been described as a stressful, intimidating and frightening experience [47]. A survey of consultant psychiatrists in Scotland also found that difficult patient behaviour was a negative influence on career choice of medical students [48]. Seeing patients recover is associated with positive views, and while this can be unpredictable, the clerkship should attempt to provide opportunities for students to have involvement in situations where the positive outcomes of treatment and management can be seen [49]. While acknowledging that local factors play a part in the clinical experience and are largely unmodifiable at a faculty level, an understanding by teachers of how students learn and basic pedagogic theory may be helpful in overcoming negative views developed during the clerkship [50]. In many of the reviewed studies, attitudes to psychiatry were positive at the beginning of the clerkship, suggesting that the pre-clinical years play an important role in fostering attitudes ahead of the clinical clerkship. Positive attitudes pre-clerkship often improve further post-clerkship, and this is a strong predictor of specialisation in to psychiatry. Timing of the clerkship (if it takes place at the beginning or end of the academic year) [44, 51] and clerkship length appear to have no impact on eventual choice of psychiatry as a career [52]. Clerkship and Recruitment to Psychiatry The question of the role of the clerkship as a recruitment tool has been raised [6]. As only a small proportion of students will eventually specialise as psychiatrists perhaps, there should be more focus on what makes a good clerkship for the majority of students who will end up in primary care or generalist settings. To achieve this, the clerkship experience needs to equip students with the basic skills and competencies important for all doctors, regardless of eventual area of specialisation. The ability to assess suicide risk, manage alcohol withdrawal, diagnosis and management of depression and assessment of substance misuse have been identified as important skills for students to learn in the clerkship [53].
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As psychiatric educators, we need to target strategies to positively influence students towards a career in psychiatry, both pre- and post-clerkship. Addressing stigma throughout the curriculum could play an important role in overcoming negative perceptions towards psychiatry and mental illness, particularly when students are exposed to clinical situations during the clerkship [54, 55]. Students are often influenced by a particularly charismatic and enthusiastic consultant or registrar involved in the clerkship [20, 24, 40, 49]. Identifying positive role models, mentorship [3, 46, 50] and the implementation of enrichment programmes to nurture and encourage interested students [56, 57] may prevent the deterioration in attitudes that occurs post-clerkship. Limitations of this review are that only papers published in English were included, which may have excluded some relevant studies. Due to variations in the length and structure of clerkships, local nuances and differences in methodologies between studies, the conclusions drawn from the reviewed studies need to be interpreted with caution. Specific elements found to be successful in one university may not necessarily translate to another. Finally, in order to make the synthesis of studies of greater significance to contemporary teaching, the review was restricted to studies from 1990 onwards. Despite these limitations, the review has highlighted a range of factors, both positive and negative regarding the impact of psychiatry clerkships. Career decision making for medical students is a competitive process. For an unpopular specialty such as psychiatry, the clerkship provides a crucial opportunity to positively influence students. However, fostering positive attitudes must begin in the pre-clinical years. Destigmatisation strategies and effective teaching of communication and history taking skills will help prepare students for the realities of the clerkship and enable them to make the most of the experience. Maintaining interest post-clerkship so that these students are not lost as they progress through the course is essential. While this may be considered as an additional workload, with administrative and departmental assistance, it could become a constructive factor in increasing recruitment rates. Finally, future research needs to identify components of the clerkship that are rated positively in order to improve student attitudes and encourage a career in psychiatry. Implications for Educators & Clerkships provide educators with the opportunity to positively influence students' attitudes towards psychiatry. & Clerkships need to be structured so that students have a variety of clinical experiences that limit exposure to the more negative aspects of clinical psychiatry such as acute and emergency settings. & Teaching and learning activities in the pre-clinical years have the potential to foster positive attitudes to psychiatry and address pre-existing stigmatising attitudes to mental illness.
Acad Psychiatry (2014) 38:35–42 Implications for Academic Leaders & Awareness of stigma and its role in adversely impacting on psychiatry as a career choice needs to be recognised. & While attitudes towards psychiatry are positive, the clerkship does not serve as an effective strategy to recruit students to a career in psychiatry. & Identifying students who are interested in psychiatry during the clerkship and introducing them to positive role models and mentoring relationships could play an important part in increasing recruitment rates.
Disclosures No conflicts of interest are identified in the preparation of this article.
References 1. Lyons Z. Attitudes of medical students towards psychiatry, and to psychiatry as a career: a systematic review. Acad Psychiatry 2012; 37:150-7 2. Walton H, Gelder M. Core curriculum in psychiatry for medical students. Med Educ. 1999;33:204–11. 3. Eagles J, Wilson S, Murdoch J, Brown T. What impact do undergraduate experiences have upon recruitment into psychiatry? Psychiatr Bull. 2007;31:70–2. 4. Feldmann T. Medical students' attitudes toward psychiatry and mental disorders. Acad Psychiatry. 2005;29:354–6. 5. Serby M, Schmeidler J, Smith J. Length of psychiatry clerkships: recent changes and the relationship to recruitment. Acad Psychiatry. 2002;26:102–4. 6. Balon R. Does a clerkship in psychiatry affect medical students' attitudes toward psychiatry? Acad Psychiatry. 2008;32:73–5. 7. Adebowale T, Adelufosi A, Ogunwale A, Abayomi O, Ojo T. The impact of a psychiatry clinical rotation on the attitude of Nigerian medical students to psychiatry. Afr J Psychiatry. 2012;15:185–8. 8. Rodrigo A, Wijesinghe C, Kuruppuarachchi K. Changes in attitudes toward psychiatry with introduction of a new curriculum: experiences of a Sri Lankan medical school. SL J Psychiatry. 2012;3:14–6. 9. Xavier M, Almeida J. Impact of clerkship in the attitudes toward psychiatry among Portuguese medical students. BMC Med Educ 2010;10:56 10. El-Gilany A, Amr M, Iqual R. Students' attitudes toward psychiatry at Al-Hassa Medical College, Saudi Arabia. Acad Psychiatry. 2010;34: 71–4. 11. Aghukwa C. Medical students' beliefs and attitudes toward mental illness: effects of a psychiatric education. Acad Psychiatry. 2010;34: 67–70. 12. Sajid A, Khan M, Shakir M, Moazam-Zaman R, Ali A. The effect of clinical clerkship on students' attitudes toward psychiatry in Karachi, Pakistan. Acad Psychiatry. 2009;33:212–4. 13. Issa B, Adegunloye O, Yussuf A, Oyewole O, Fatoye F. Attitudes of medical students to psychiatry at a Nigerian medical school. Hong Kong J Psychiatry. 2009;19:72–7. 14. Ramamurthy C, Srikumar P, Joshua E, Rasamy G. Impact of psychiatry training on attitudes of undergraduate medical students. Malay J Psychiatry 2008;21:22–31 15. Fischel T, Manna H, Krivoy A, Lewis M, Weizman A. Does a clerkship in psychiatry contribute to changing medical students attitudes towards psychiatry? Acad Psychiatry. 2008;32: 147–50.
41 16. Al-Adawi S, Dorvlo A, Bhaya C, et al. Withering before the sowing? A survey of Oman's ‘Tomorrow's Doctors’ interest in psychiatry. Educ Health. 2008;21:1–10. 17. Kuhnigk O, Strebel B, Schilauske J, Jueptner M. Attitudes of medical students towards psychiatry: effects of training, courses in psychiatry, psychiatric experience and gender. Adv Health Sci Educ. 2007;12: 87–101. 18. Holm-Petersen C, Vinge S, Hansen J, Gyrd-Hansen G. The impact of contact with psychiatry on senior medical students attitudes toward psychiatry. Acta Psychiatr Scand. 2007;116:308–11. 19. Samimi M, Noroozi A, Mottaghipour Y. The effect of psychiatric clerkship on fifth year medical students' attitudes toward psychiatry and their intention to pursue psychiatry as a career. Iran J Psychiatry. 2006;1:98–103. 20. Niedermier J, Bornstein J, Brandemihl A. The junior medical student psychiatry clerkship: curriculum, attitudes, and test performance. Acad Psychiatry. 2006;30:136–43. 21. Reddy JP, Tan SM, Azmi MT, et al. The effect of a clinical posting in psychiatry on the attitudes of medical students towards psychiatry and mental Illness in a Malaysian medical school. AAMS. 2005;34: 505–10. 22. Galka S, Perkins D, Butler N, et al. Medical students' attitudes toward mental disorders before and after a psychiatric rotation. Acad Psychiatry. 2005;29:357–61. 23. Bulbena A, Pailhez G, Coll J, Balon R. Changes in the attitudes towards psychiatry among Spanish medical students during training in psychiatry. Eur J Psychiat. 2005;19:79–87. 24. McParland M, Noble L, Livingston G, McManus C. The effect of a psychiatric attachment on students' attitudes to and intention to pursue psychiatry as a career. Med Educ. 2003;37:447–54. 25. Olotu O, Osahon R. The effects of a clinical posting in psychiatry on the beliefs and attitudes of medical students towards the discipline. Nigerian J Psychiatry 2001;1 26. Singh S, Baxter H, Standen P, Duggan C. Changing the attitudes of ‘tomorrow's doctors’ towards mental illness and psychiatry: a comparison of two teaching methods. Med Educ. 1998;32:115–20. 27. Garyfallos G, Adamopoulou A, Lavrentiadis G, et al. Medical students' attitudes toward psychiatry in Greece: an eight-year comparison. Acad Psychiatry. 1998;22:92–7. 28. Arkar H, Eker D. Influence of a 3-week psychiatric training programme on attitudes toward mental illness in medical students. Soc Psychiatr Psychiatr Epidemiol. 1997;32:171–6. 29. Sloan D, Browns S, Meagher D, et al. Attitudes toward psychiatry among Irish final year medical students. Eur Psychiatry. 1996;11: 407–11. 30. Guttmann F, Rosca-Rebaudengo P, Davis H. Changes in attitudes of medical students towards psychiatry: an evaluation of a clerkship in psychiatry. Isr J Psychiatry Relat Sci. 1996;33:158–66. 31. Galletly G, Schruder G, Chesteman H, Tsourtos G. Medical student attitudes to psychiatry: lack of effect of psychiatric hospital experience. Med Educ. 1995;29:449–51. 32. Araya R, Jadresic E, Wilkinson G. Medical students' attitudes to psychiatry in Chile. Med Educ. 1992;26:153–6. 33. Burra P, Kalin R, Leichner P, et al. The ATP 30—a scale for measuring medical students' attitudes to psychiatry. Med Educ. 1982;16:31–8. 34. Balon R, Franchini G, Freeman P, et al. Medical students' attitudes and views of psychiatry: 15 years later. Acad Psychiatry. 1999;23: 30–6. 35. Nielsen A, Eaton J. Medical students' attitudes about psychiatry: implications for psychiatric recruitment. Arch Gen Psychiatry. 1981;38:1144–54. 36. Wilkinson D, Greer S, Toone B. Medical students' attitudes to psychiatry. Psychol Med. 1983;13:185–92. 37. Nevid J, Morrison J. Attitudes toward mental illness: the construction of the Libertarian Mental Health Ideology Scale. J Humanist Psychol. 1980;20:71–85.
42 38. Das M, Chandrasena R. Medical students’ attitudes towards psychiatry. Can J Psychiatry. 1988;33:783–7. 39. Creed F, Goldberg D. Students’ attitudes towards psychiatry. Med Educ. 1987;21:227–34. 40. Maidment R, Livingston G, Katona C, McParland M, Noble L. Change in attitudes to psychiatry and intention to pursue psychiatry as a career in newly qualified doctors: a follow-up of two cohorts of medical students. Med Teach. 2004;26:565–9. 41. Baxter H, Singh S, Standen P, Duggan C. The attitudes of `tomorrow’s doctors' towards mental illness and psychiatry: changes during the final undergraduate year. Med Educ. 2001;35:381–3. 42. Brooks C. The influence of medical school clinical experiences on career preferences: a multidimensional perspective. Soc Sci Med. 1991;32:327–32. 43. Bobo W, Nevin R, Greene E, Lacy T. The effect of psychiatric thirdyear rotation setting on academic performance, student attitudes, and specialty choice. Acad Psychiatry. 2009;33:105–11. 44. Clardy J, Thrush C, Guttenberger V, Goodrich M, Burton R. The junior-year psychiatric clerkship and medical students’ interest in psychiatry. Acad Psychiatry. 2000;24:35–40. 45. Gerbase M, Germond M, Mathieu R, Nendaz M, Vu N. When the evaluated becomes evaluator: what can we learn from students’ experiences during clerkships? Acad Med. 2009;84: 877–85. 46. Ellsbury K, Carline J, Irby D, Stritter D. Influence of third-year clerkships on medical student specialty preferences. Adv Health Sci Educ. 1998;3:177–86.
Acad Psychiatry (2014) 38:35–42 47. Pessar L, Pristach C, Leonard K. What troubles clerks in psychiatry? A strategy to explore the question. Acad Psychiatry. 2008;32:194–8. 48. Brown T, Addie K, Eagles J. Recruitment into psychiatry: views of consultants in Scotland. Psychiatrist. 2007;31:411–3. 49. Lampe L, Coulston C, Walter G, Malhi G. Familiarity breeds respect: attitudes of medical students towards psychiatry following a clinical attachment. Australas Psychiatry. 2010;18:348–53. 50. El-Sayeh H, Budd S, Waller R, Holmes J. How to win the hearts and minds of students in psychiatry. Adv Psychiatr Treat. 2006;12:182–92. 51. Park R, Chibnall J, Morrow A. Relationship of rotation timing to pattern of clerkship performance in psychiatry. Acad Psychiatry. 2005;29:267–73. 52. Serby M, Schmeidler J, Smith J. Length of psychiatry clerkships recent changes and the relationship to recruitment. Acad Psychiatry. 2002;26:102–4. 53. Oakley C, Oyebode F. Medical students' views about an undergraduate curriculum in psychiatry before and after clinical placements. BMC Med Ed 2008;8:26 54. Brenner A. What medical students say about psychiatry: results of a reflection exercise. Acad Psychiatry. 2011;35:196–8. 55. Roberts L, Bandstra B. Addressing stigma to strengthen psychiatric education. Acad Psychiatry 2012;36:347-50 56. Lyons Z, Power B, Bilyk N, Lofchy J, Claassen J. Evaluation of the Claassen Institute of Psychiatry for Medical Students. Australas Psychiatry. 2010;18:12–6. 57. Manassis K, Katz M, Lofchy J, Wiesenthal S. Choosing a career in psychiatry: influential factors within a medical school program. Acad Psychiatry. 2006;30:325–9.
IN DEPTH ARTICLE: SYSTEMATIC REVIEW
Impact of the Psychiatry Clerkship on Medical Student Attitudes Towards Psychiatry and to Psychiatry as a Career Zaza Lyons
Received: 12 December 2012 / Accepted: 26 April 2013 / Published online: 24 January 2014 # Academic Psychiatry 2014
Abstract Objective The psychiatry clerkship forms part of the core curriculum of medical schools worldwide and provides psychiatric educators with an ideal opportunity to positively influence students. The aim of this paper is to systematically review literature on the impact of the psychiatry clerkship to determine the effect on attitudes towards psychiatry and to psychiatry as a career. Method A systematic review was undertaken. The following key search words were used to search a number of electronic databases: medical student/s, attitude/s, psychiatry and clerkship. Studies published in the English language from 1990 to the present were included. Studies were included if they were based on a pre-/post-design, i.e. the same students must have participated in the study both before and after the clerkship. Results Twenty-six studies from 19 countries were identified for the review. Sixteen studies reported an overall improvement in attitudes towards psychiatry post-clerkship, and ten found no change in attitudes. In terms of career choice, nine studies reported an increase in the number of students interested in psychiatry as a career post-clerkship, nine found no impact on career choice and, in eight studies, it was not assessed. A number of positive and negative factors regarding the clerkship were identified. Conclusion Overall, the psychiatry clerkship has a positive impact on students' attitudes towards psychiatry, but does not improve interest in psychiatry as a career option. For those students particularly interested in psychiatry, the challenge is to maintain their enthusiasm post-clerkship. Charismatic teachers, mentorship and stigma reduction may be effective
Z. Lyons (*) University of Western Australia, Crawley, WA, Australia e-mail: [email protected]
strategies. Future research needs to more clearly identify specific components of the clerkship that are viewed favorably by students. Keywords Medical student . Impact . Clerkship . Attitudes . Psychiatry Attitudes of medical students towards psychiatry have been extensively studied over the last three decades. A recently published review of 32 studies showed that, overall, students' views are generally more positive than negative; however, the proportion who choose psychiatry as a career remains low [1]. Psychiatry is now firmly embedded as part of the core curriculum in all medical courses [2]. A combination of different teaching techniques, including problem-based and didactic learning, and clinical clerkships is used to teach students the skills, attitudes and knowledge relevant to the discipline of psychiatry [2]. For students in the clinical years, clerkships provide a more realistic view of psychiatry than may have been gained through lectures and tutorial sessions during the pre-clinical years. These experiences can become important factors in later career decision making [3, 4]. Clerkships are usually between 4 and 8 weeks in length (average 6.3 weeks) [5] and, in most courses, are the only clinical exposure that students have of psychiatry. This provides a narrow window to ensure that the experience is positive and emphasis on ‘getting it right’ becomes imperative. The clerkship gives psychiatric educators an ideal opportunity to positively influence students, and while there is no doubt that the experience has an impact on attitudes, there is less clarity from the existing literature on the strength and direction of this change [6]. The aim of this systematic review is to determine the impact of the psychiatry clerkship on attitudes of medical
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students towards psychiatry and to psychiatry as a career choice. A more comprehensive viewpoint of the effectiveness of clerkships may enable psychiatric educators to use the clerkship effectively to ensure that it provides students with a beneficial learning experience and improves their attitude towards psychiatry and to psychiatry as a career choice. It should be noted that, for consistency in terminology, the word clerkship is used throughout this paper and is synonymous with rotation, attachment, posting and other similar terms that may be used as local equivalents.
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these articles to identify those meeting the selection criteria was undertaken by the author and resulted in the identification of 42 papers. In order to minimize selection bias, a senior colleague undertook a further independent assessment of these papers. They were then were read in full to determine suitability for inclusion in the review. Sixteen papers were excluded, leaving 26 that were finally selected. Papers were excluded if they were not based on a pre-/post-design; students were surveyed retrospectively; or pre/post measures were performed on different student cohorts.
Results Method Summary of Main Findings The method used was consistent with the previous systematic review undertaken by the author [1]. The following electronic databases were searched: MEDLINE, EMBASE, Web of Science, ScienceDirect, AustHealth (Informit), CINAHL Plus (Ebsco), Global Health (Ovid), Health and Medical Complete (Proquest) and PsychInfo. In addition, the reference lists of studies included in the review were hand searched. Finally, using the available online archive search functions, each available issue from key journals was hand-searched. These were Academic Psychiatry, Medical Education, Medical Teacher and Academic Teacher. Searches for personal communications and conference data were not undertaken. Search words used were medical student/s, attitude/s, psychiatry and clerkship. In order to include words synonymous with ‘clerkship’ the following terms were also acceptable: rotation, attachment, posting, affiliation, training programme and education. The following criteria were used to determine inclusion of papers for the review: (1) must have been published in an English language, peer reviewed journal from 1990 onwards; (2) all the search words to appear in the title and/or abstract; and (3) reporting primary research with medical students as respondents. Studies were included if they were based on a pre-/postdesign, i.e. the same students participated in the study both before and after clerkship. This was to ensure that only studies specifically assessing the impact of the clerkship were included. The previous review [1] focused on the cross-sectional assessment of students' attitudes towards psychiatry and did not include clerkship studies. The following information was extracted from each paper: year of publication, country where the study was conducted, aim/s, sample size and response rate, year of course in which the clerkship took place, length of clerkship and main results. A global ‘yes/no’ assessment to indicate if overall attitudes to psychiatry had improved post-clerkship was made. The electronic search identified 315 papers that had any one of the key search words in its title. An initial screening of
All 26 studies assessed the impact of the clerkship on student attitudes and were based on a pre-/post-design, where students were asked to complete questionnaires at the beginning and end of the clerkship. Eighteen studies also assessed the impact on career choice. A summary of each study including author, country where conducted, aims, year level surveyed, length of clerkship and overall improvement post-clerkship is shown in Table 1. Overall, 16 studies reported an improvement in attitudes towards psychiatry post-clerkship. The remaining ten concluded that the clerkship had not changed attitudes. In terms of career choice, nine studies reported an increase in the number of students interested in psychiatry as a career postclerkship, nine found no impact on career choice and, in eight studies, it was not assessed. The reviewed studies were conducted in 19 different countries. There were four from Nigeria, two each from Malaysia, UK, Israel and USA, and one study from each of the following countries: Australia, Sri Lanka, Portugal, Saudi Arabia, Pakistan, Oman, Germany, Denmark, Iran, Spain, Greece, Turkey, Ireland and Chile. Design of Studies Several different validated questionnaires were used to survey students. Eight studies [7, 8, 13, 17, 21, 24, 26, 29] used the ATP-30 [33], four [9, 10, 14, 23] used the Balon questionnaire [34], two [15, 19] the Nielsen and Eaton questionnaire [35] and two [31, 32] a questionnaire designed by Wilkinson [36]. One study [27] used the Libertarian Mental Health Scale [37] and one [16] a questionnaire by Das and Chandrasena [38]. The remaining eight developed their own questionnaires. A total of 3,747 students participated in completing baseline and follow-up questionnaires. One study used a control group of students doing an ophthalmology clerkship [28], and two assessed different courses resulting from recent curriculum changes [24, 26]. Two studies surveyed other year levels
To examine the impact of clerkship on attitudes to psychiatry and career. Year 5; 4 weeks To assess the effect of new clerkship on career choice and attitudes towards psychiatry. Final year students; 8 weeks To evaluate attitudes to psychiatry and as a career. New curriculum and clerkship model. Year 6; 4 weeks To understand changes in attitudes to psychiatry post clerkship. Year 5; 6 weeks To examine impact of clerkship on beliefs and attitudes towards mental illness. Final year students; 4 weeks To determine change in attitudes following clerkship. Year 4; 4 weeks To report impact of the clerkship on attitudes towards psychiatry. Final year students; 4 weeks To assess the impact of the clerkship on attitudes to psychiatry. Year level not stated; 6 weeks To assess the impact of the clerkship on attitudes to psychiatry of Israeli students and US students studying in Israel. Year level not stated; 5 weeks To explore attitudes and career intentions. Year level not stated; 8 weeks To assess students attitudes in 4 different semesters to psychiatry and determine if these change during medical school. Students in year 5 only surveyed pre and post clerkship. Length of clerkship not stated To assess change in attitudes after clerkship and impact on career. Years 4 and 5 at 3 universities; 4 weeks
2012, Adebowale et al., Nigeria [7]
2012, Rodrigo et al., Sri Lanka [8]
2010, Xavier. Portugal [9]
2010, El-Gilany et al., Saudi Arabia [10]
2010, Aghukwa, Nigeria [11]
2009, Sajid et al., Pakistan [12]
2009, Issa et al., Nigeria [13]
2008, Ramamurthy et al., Malaysia [14]
2008, Fischel, Israel [15]
2008, Al-Adawi et al., Oman [16]
2007, Kuhnigk et al., Germany [17]
To assess impact of clerkship on changes in attitudes and career. Year 5; 4 weeks To assess attitudes towards clerkship and various aspects of the curriculum and teaching. Year 3; 4 weeks To examine the impact of clerkship on attitudes to mental illness and psychiatry. Year 4; 8 weeks To examine attitudes to mental illness before and after clerkship. Year 3; 6 weeks To gain understanding of choosing psychiatry as a career and how attitudes change during academic year. Year 4; 6 weeks
2006, Samimi et al., Iran [19]
2006, Niedermier et al., US [20]
2005, Reddy et al., Malaysia [21]
2005, Galka et al., US [22]
2005, Bulbena et al., Spain [23]
2007,Holm-Petersen et al., Denmark [18]
Aims, year/s surveyed, length of clerkship
Year, author, country
Table 1 Summary of reviewed studies
100 % (48) pre and post
70 % (672) pre and post
Sem 10 students: 100 % (136) pre 93 % (127) post 73 % (223) pre 70 % (214) post 87 % (109) pre 87 % (109) post (184) pre (184) post RR not given 70 % (122) pre and post
83 % (171)
75 % (67) pre 53 % (47) post 100 % (126) pre 100 % (135) post 78 % (91) pre 76 % (89) post Israeli: (29); U.S. (28) RR not given
N =35 pre and post
96.4 % (54) pre and post
66.9 % (81) pre 88 % (106) post 91 % (91) pre 93 % (93) post 100 % (153) pre and post
Response rate, sample size
Attitudes—yes Career—yes Attitudes—yes Career—no Attitudes—yes Career—yes
Career—no
Attitudes—yes Career—yes Attitudes—yes Career—yes Attitudes—yes
Career—no Attitudes—no Career—no
Attitudes—yes Career—no Attitudes—no Career—yes Attitudes—no Career—N/A Attitudes—no Career—N/A Attitudes—yes
Attitudes—yes Career—no Attitudes—no Career—yes Attitudes–yes Career—yes Attitudes—yes Career—N/A Beliefs and attitudes—no Career—N/A
Overall improvement post-clerkship
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Aims, year/s surveyed, length of clerkship
To assess attitudes to psychiatry, career intentions and experiences during the clerkship. Year 4; 8 weeks. 2 cohorts—one traditional content, one PBL To evaluate impact of clerkship on beliefs and attitudes towards psychiatry. Year 5; 8 weeks To compare efficacy of new curriculum (vs old) of students attitudes to psychiatry and mental illness. Year 4; 8 weeks (old); 6 weeks (new) To compare attitudes of a previous sample (1985) of students with current students (1993) before and after clerkship. Year 4; 16 weeks (1 day/week) To compare attitudes to mental illness between students doing psychiatry clerkship with those doing ophthalmology clerkship. Year 5; 3 weeks To measure the impact of clerkship on attitudes. Final year students; 8 weeks To evaluate student attitudes before and after clerkship. Year 5; 5 weeks To assess changes in attitudes after clerkship. Final year students; 4 weeks To assess changes in attitudes after clerkship and determine if these change over time. Year 3 (no exposure); Year 5; 8 weeks; interns
Year, author, country
2003, McParland et al., UK [24]
2001, Oluto & Osahon, Nigeria [25]
1998, Singh & Baxter, UK [26]
1998, Garyfallos et al., Greece [27]
1997, Arkar & Eker, Turkey [28]
1996, Sloan et al., Ireland [29]
1996, Guttmann et al., Israel [30]
1995,Galletly et al., Australia [31]
1992, Arya et al., Chilie [32]
Table 1 (continued)
Year 3: 94 % (75) pre 100 % (80) post Year 5: 80 % (48) pre 90 % (54) post Interns: 85 % (56) pre 74 % (49) post
(153) pre and post RR not given
88 % (53) pre 72 % (43) post
(75) psyc group (60) opth group RR not given 95 % (110)—from 3 med colleges
90.3 % (140) 1993 (51) 1985
90 % (110) pre and post
(105) pre and post RR not given
84 % (379) pre and post
Response rate, sample size
Attitudes—yes Career—no
Attitudes—yes Career—yes Attitudes—no Career—N/A Attitudes—no Career—no
Attitudes—yes Career—yes Attitudes—no Career—no Attitudes—yes Career—N/A Attitudes—yes Career—N/A Attitudes—no Career—N/A
Overall improvement post-clerkship
38 Acad Psychiatry (2014) 38:35–42
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as well as the year group undertaking the clerkship as a means of determining changes in attitudes at different stages of training [17, 32]. Two studies surveyed students from more than one medical school [18, 29]. Response rates ranged from 100 to 50 %. The average length of clerkship was 5.5 weeks, range of 3– 16 weeks. In nine studies (35 %), it was 4 weeks; in seven studies (30 %), it was 8 weeks; in five studies (19 %), it was 6 weeks, two studies (8 %) had a 5 week clerkship; and two others (8 %) had 3 and 16 week clerkships, respectively (NB; students in this study spent only 1 day/week in a clinical setting). In one, the length of clerkship was not stated. It is not possible from the information provided to determine if the clerkship described in the study represented the only clinical exposure to psychiatry that students had, or if further clerkships occurred at different times. There was no identifiable trend between length of clerkship (shorter or longer) and improvement in attitudes or career choice.
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exposure with patient contact. Across studies, non-clinical content was mainly comprised of lectures [7, 10, 13–15, 19, 28, 29], tutorials, including PBL [10, 11, 14], seminars [7, 9, 22], theory lessons [9–11, 23, 27], diagnostic classification [13, 27], case presentations and histories [12, 15], journal club [12], history taking and interviewing skills [13, 29], formulation [29], small group discussions [10, 12], research project and self-directed learning activities [14]. For the clinical component, the most prominent features in all studies were exposure to adult inpatient wards and outpatient clinics. Other features included acute wards/emergency departments [8, 9, 23, 27], rehabilitation [9, 29], community liaison [8, 9, 13, 20], child and adolescent psychiatry [8, 9, 13, 20, 22, 23, 29], old age psychiatry [13], addiction medicine/ substance abuse [8, 13], forensic psychiatry [13, 29], centre for learning disabilities [29], psychotherapy [13], ward rounds [11, 29], experience of closed wards [15], electro convulsive treatment (ECT) [13, 20] and evening on call [20].
Impact of Clerkship on Attitudes and Career Choice Discussion Attitudes were often positive at the beginning of the clerkship and improved further post-clerkship. Inevitably, most studies reported a mix of views that improved, deteriorated or showed no change post-clerkship. Some studies found that students with more positive attitudes correlated with greater interest in psychiatry as a career and higher exam results. Female students showed greater improvement in attitudes post-clerkship than male students in four studies [7, 16, 21, 32]. Age was reported in less than half the studies reviewed, and overall, it was not possible to determine if it was a factor in postclerkship attitude change. An improvement in views postclerkship was found in the following areas: value and experience of psychiatric teaching [8–10, 17], effectiveness of treatment/consultation [8–10, 16, 21, 22], scientific basis of psychiatry [9], specialization of psychiatry and psychiatrists as professionals [9, 10, 16, 18, 23], causes/beliefs towards mental illness [11, 22] patients [12, 13, 18, 21], merits of psychiatry [14, 30], improvement in clinical skills and understanding patients feelings [30]. No change, or a deterioration in views, was reported in a number of important areas by some studies—attitudes towards mental illness and patients [11, 13, 25, 28], teaching of psychiatry [12, 23], psychiatry as a discipline and psychiatrists [13–15, 30], knowledge in psychiatry [15], merits of psychiatry [23], treatment/prognosis [23, 30] and the scientific basis of psychiatry [30]. Clerkship Structure Most studies provided some information about the structure of the clerkship. While this varied considerably between courses, all provided a mix of non-clinical teaching and clinical
Despite differences in both the length and structure of the clerkship between medical schools that make it difficult for direct comparisons to be made, of the 26 studies reviewed, 16 (61 %) showed that students' attitudes improved postclerkship. However, the impact on career choice was less positive, with only nine out of 18 studies that assessed career choice finding that the clerkship increased students' interest in psychiatry as a career. While the improvement in attitudes post-clerkship is positive, these effects decay as students' progress through the medical course and into internship [39–41]. Career preferences also fluctuate as students advance through the clinical years, as exposure to different areas of specialization and acquisition of new skills and knowledge enables them to assess their interest in each area and determine its suitability as a career [42]. Positive Clerkship Factors The basic structure of the clerkship combines lectures, tutorials and other non-clinical activities with the clinical attachment, usually based in hospitals and outpatient clinics. The experiences gained during the clinical component of the clerkship, however, are more likely to influence students' attitudes than the non-clinical teaching activities. Different settings (outpatient clinic, hospital based consultation liaison service, and acute inpatient ward) have been found to have little impact on eventual career choice, examination marks or psychiatric knowledge [43]. However, an outpatient clerkship may have a more positive effect on career choice [44]. Other factors that constitute a good clerkship experience have been identified as the quality of the clinical teaching, the organisation of the
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clerkship and its supervision and learning activities [45]. The opportunity to develop close personal relationships with patients, deal with challenging diagnoses and a diversity of clinical experiences are also influential aspects in specialty choice [46]. From a student's perspective, an important aspect of any clerkship is patient contact and the relationship with patients that develops during the clerkship [46]. Some studies have shown that students' attitudes towards patients improved post-clerkship, and patient contact was regarded as a rewarding aspect [12, 18, 20, 26]. Others, however, have not shown improvement [13, 28] and patient behaviour, particularly in acute inpatient settings, has been described as a stressful, intimidating and frightening experience [47]. A survey of consultant psychiatrists in Scotland also found that difficult patient behaviour was a negative influence on career choice of medical students [48]. Seeing patients recover is associated with positive views, and while this can be unpredictable, the clerkship should attempt to provide opportunities for students to have involvement in situations where the positive outcomes of treatment and management can be seen [49]. While acknowledging that local factors play a part in the clinical experience and are largely unmodifiable at a faculty level, an understanding by teachers of how students learn and basic pedagogic theory may be helpful in overcoming negative views developed during the clerkship [50]. In many of the reviewed studies, attitudes to psychiatry were positive at the beginning of the clerkship, suggesting that the pre-clinical years play an important role in fostering attitudes ahead of the clinical clerkship. Positive attitudes pre-clerkship often improve further post-clerkship, and this is a strong predictor of specialisation in to psychiatry. Timing of the clerkship (if it takes place at the beginning or end of the academic year) [44, 51] and clerkship length appear to have no impact on eventual choice of psychiatry as a career [52]. Clerkship and Recruitment to Psychiatry The question of the role of the clerkship as a recruitment tool has been raised [6]. As only a small proportion of students will eventually specialise as psychiatrists perhaps, there should be more focus on what makes a good clerkship for the majority of students who will end up in primary care or generalist settings. To achieve this, the clerkship experience needs to equip students with the basic skills and competencies important for all doctors, regardless of eventual area of specialisation. The ability to assess suicide risk, manage alcohol withdrawal, diagnosis and management of depression and assessment of substance misuse have been identified as important skills for students to learn in the clerkship [53].
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As psychiatric educators, we need to target strategies to positively influence students towards a career in psychiatry, both pre- and post-clerkship. Addressing stigma throughout the curriculum could play an important role in overcoming negative perceptions towards psychiatry and mental illness, particularly when students are exposed to clinical situations during the clerkship [54, 55]. Students are often influenced by a particularly charismatic and enthusiastic consultant or registrar involved in the clerkship [20, 24, 40, 49]. Identifying positive role models, mentorship [3, 46, 50] and the implementation of enrichment programmes to nurture and encourage interested students [56, 57] may prevent the deterioration in attitudes that occurs post-clerkship. Limitations of this review are that only papers published in English were included, which may have excluded some relevant studies. Due to variations in the length and structure of clerkships, local nuances and differences in methodologies between studies, the conclusions drawn from the reviewed studies need to be interpreted with caution. Specific elements found to be successful in one university may not necessarily translate to another. Finally, in order to make the synthesis of studies of greater significance to contemporary teaching, the review was restricted to studies from 1990 onwards. Despite these limitations, the review has highlighted a range of factors, both positive and negative regarding the impact of psychiatry clerkships. Career decision making for medical students is a competitive process. For an unpopular specialty such as psychiatry, the clerkship provides a crucial opportunity to positively influence students. However, fostering positive attitudes must begin in the pre-clinical years. Destigmatisation strategies and effective teaching of communication and history taking skills will help prepare students for the realities of the clerkship and enable them to make the most of the experience. Maintaining interest post-clerkship so that these students are not lost as they progress through the course is essential. While this may be considered as an additional workload, with administrative and departmental assistance, it could become a constructive factor in increasing recruitment rates. Finally, future research needs to identify components of the clerkship that are rated positively in order to improve student attitudes and encourage a career in psychiatry. Implications for Educators & Clerkships provide educators with the opportunity to positively influence students' attitudes towards psychiatry. & Clerkships need to be structured so that students have a variety of clinical experiences that limit exposure to the more negative aspects of clinical psychiatry such as acute and emergency settings. & Teaching and learning activities in the pre-clinical years have the potential to foster positive attitudes to psychiatry and address pre-existing stigmatising attitudes to mental illness.
Acad Psychiatry (2014) 38:35–42 Implications for Academic Leaders & Awareness of stigma and its role in adversely impacting on psychiatry as a career choice needs to be recognised. & While attitudes towards psychiatry are positive, the clerkship does not serve as an effective strategy to recruit students to a career in psychiatry. & Identifying students who are interested in psychiatry during the clerkship and introducing them to positive role models and mentoring relationships could play an important part in increasing recruitment rates.
Disclosures No conflicts of interest are identified in the preparation of this article.
References 1. Lyons Z. Attitudes of medical students towards psychiatry, and to psychiatry as a career: a systematic review. Acad Psychiatry 2012; 37:150-7 2. Walton H, Gelder M. Core curriculum in psychiatry for medical students. Med Educ. 1999;33:204–11. 3. Eagles J, Wilson S, Murdoch J, Brown T. What impact do undergraduate experiences have upon recruitment into psychiatry? Psychiatr Bull. 2007;31:70–2. 4. Feldmann T. Medical students' attitudes toward psychiatry and mental disorders. Acad Psychiatry. 2005;29:354–6. 5. Serby M, Schmeidler J, Smith J. Length of psychiatry clerkships: recent changes and the relationship to recruitment. Acad Psychiatry. 2002;26:102–4. 6. Balon R. Does a clerkship in psychiatry affect medical students' attitudes toward psychiatry? Acad Psychiatry. 2008;32:73–5. 7. Adebowale T, Adelufosi A, Ogunwale A, Abayomi O, Ojo T. The impact of a psychiatry clinical rotation on the attitude of Nigerian medical students to psychiatry. Afr J Psychiatry. 2012;15:185–8. 8. Rodrigo A, Wijesinghe C, Kuruppuarachchi K. Changes in attitudes toward psychiatry with introduction of a new curriculum: experiences of a Sri Lankan medical school. SL J Psychiatry. 2012;3:14–6. 9. Xavier M, Almeida J. Impact of clerkship in the attitudes toward psychiatry among Portuguese medical students. BMC Med Educ 2010;10:56 10. El-Gilany A, Amr M, Iqual R. Students' attitudes toward psychiatry at Al-Hassa Medical College, Saudi Arabia. Acad Psychiatry. 2010;34: 71–4. 11. Aghukwa C. Medical students' beliefs and attitudes toward mental illness: effects of a psychiatric education. Acad Psychiatry. 2010;34: 67–70. 12. Sajid A, Khan M, Shakir M, Moazam-Zaman R, Ali A. The effect of clinical clerkship on students' attitudes toward psychiatry in Karachi, Pakistan. Acad Psychiatry. 2009;33:212–4. 13. Issa B, Adegunloye O, Yussuf A, Oyewole O, Fatoye F. Attitudes of medical students to psychiatry at a Nigerian medical school. Hong Kong J Psychiatry. 2009;19:72–7. 14. Ramamurthy C, Srikumar P, Joshua E, Rasamy G. Impact of psychiatry training on attitudes of undergraduate medical students. Malay J Psychiatry 2008;21:22–31 15. Fischel T, Manna H, Krivoy A, Lewis M, Weizman A. Does a clerkship in psychiatry contribute to changing medical students attitudes towards psychiatry? Acad Psychiatry. 2008;32: 147–50.
41 16. Al-Adawi S, Dorvlo A, Bhaya C, et al. Withering before the sowing? A survey of Oman's ‘Tomorrow's Doctors’ interest in psychiatry. Educ Health. 2008;21:1–10. 17. Kuhnigk O, Strebel B, Schilauske J, Jueptner M. Attitudes of medical students towards psychiatry: effects of training, courses in psychiatry, psychiatric experience and gender. Adv Health Sci Educ. 2007;12: 87–101. 18. Holm-Petersen C, Vinge S, Hansen J, Gyrd-Hansen G. The impact of contact with psychiatry on senior medical students attitudes toward psychiatry. Acta Psychiatr Scand. 2007;116:308–11. 19. Samimi M, Noroozi A, Mottaghipour Y. The effect of psychiatric clerkship on fifth year medical students' attitudes toward psychiatry and their intention to pursue psychiatry as a career. Iran J Psychiatry. 2006;1:98–103. 20. Niedermier J, Bornstein J, Brandemihl A. The junior medical student psychiatry clerkship: curriculum, attitudes, and test performance. Acad Psychiatry. 2006;30:136–43. 21. Reddy JP, Tan SM, Azmi MT, et al. The effect of a clinical posting in psychiatry on the attitudes of medical students towards psychiatry and mental Illness in a Malaysian medical school. AAMS. 2005;34: 505–10. 22. Galka S, Perkins D, Butler N, et al. Medical students' attitudes toward mental disorders before and after a psychiatric rotation. Acad Psychiatry. 2005;29:357–61. 23. Bulbena A, Pailhez G, Coll J, Balon R. Changes in the attitudes towards psychiatry among Spanish medical students during training in psychiatry. Eur J Psychiat. 2005;19:79–87. 24. McParland M, Noble L, Livingston G, McManus C. The effect of a psychiatric attachment on students' attitudes to and intention to pursue psychiatry as a career. Med Educ. 2003;37:447–54. 25. Olotu O, Osahon R. The effects of a clinical posting in psychiatry on the beliefs and attitudes of medical students towards the discipline. Nigerian J Psychiatry 2001;1 26. Singh S, Baxter H, Standen P, Duggan C. Changing the attitudes of ‘tomorrow's doctors’ towards mental illness and psychiatry: a comparison of two teaching methods. Med Educ. 1998;32:115–20. 27. Garyfallos G, Adamopoulou A, Lavrentiadis G, et al. Medical students' attitudes toward psychiatry in Greece: an eight-year comparison. Acad Psychiatry. 1998;22:92–7. 28. Arkar H, Eker D. Influence of a 3-week psychiatric training programme on attitudes toward mental illness in medical students. Soc Psychiatr Psychiatr Epidemiol. 1997;32:171–6. 29. Sloan D, Browns S, Meagher D, et al. Attitudes toward psychiatry among Irish final year medical students. Eur Psychiatry. 1996;11: 407–11. 30. Guttmann F, Rosca-Rebaudengo P, Davis H. Changes in attitudes of medical students towards psychiatry: an evaluation of a clerkship in psychiatry. Isr J Psychiatry Relat Sci. 1996;33:158–66. 31. Galletly G, Schruder G, Chesteman H, Tsourtos G. Medical student attitudes to psychiatry: lack of effect of psychiatric hospital experience. Med Educ. 1995;29:449–51. 32. Araya R, Jadresic E, Wilkinson G. Medical students' attitudes to psychiatry in Chile. Med Educ. 1992;26:153–6. 33. Burra P, Kalin R, Leichner P, et al. The ATP 30—a scale for measuring medical students' attitudes to psychiatry. Med Educ. 1982;16:31–8. 34. Balon R, Franchini G, Freeman P, et al. Medical students' attitudes and views of psychiatry: 15 years later. Acad Psychiatry. 1999;23: 30–6. 35. Nielsen A, Eaton J. Medical students' attitudes about psychiatry: implications for psychiatric recruitment. Arch Gen Psychiatry. 1981;38:1144–54. 36. Wilkinson D, Greer S, Toone B. Medical students' attitudes to psychiatry. Psychol Med. 1983;13:185–92. 37. Nevid J, Morrison J. Attitudes toward mental illness: the construction of the Libertarian Mental Health Ideology Scale. J Humanist Psychol. 1980;20:71–85.
42 38. Das M, Chandrasena R. Medical students’ attitudes towards psychiatry. Can J Psychiatry. 1988;33:783–7. 39. Creed F, Goldberg D. Students’ attitudes towards psychiatry. Med Educ. 1987;21:227–34. 40. Maidment R, Livingston G, Katona C, McParland M, Noble L. Change in attitudes to psychiatry and intention to pursue psychiatry as a career in newly qualified doctors: a follow-up of two cohorts of medical students. Med Teach. 2004;26:565–9. 41. Baxter H, Singh S, Standen P, Duggan C. The attitudes of `tomorrow’s doctors' towards mental illness and psychiatry: changes during the final undergraduate year. Med Educ. 2001;35:381–3. 42. Brooks C. The influence of medical school clinical experiences on career preferences: a multidimensional perspective. Soc Sci Med. 1991;32:327–32. 43. Bobo W, Nevin R, Greene E, Lacy T. The effect of psychiatric thirdyear rotation setting on academic performance, student attitudes, and specialty choice. Acad Psychiatry. 2009;33:105–11. 44. Clardy J, Thrush C, Guttenberger V, Goodrich M, Burton R. The junior-year psychiatric clerkship and medical students’ interest in psychiatry. Acad Psychiatry. 2000;24:35–40. 45. Gerbase M, Germond M, Mathieu R, Nendaz M, Vu N. When the evaluated becomes evaluator: what can we learn from students’ experiences during clerkships? Acad Med. 2009;84: 877–85. 46. Ellsbury K, Carline J, Irby D, Stritter D. Influence of third-year clerkships on medical student specialty preferences. Adv Health Sci Educ. 1998;3:177–86.
Acad Psychiatry (2014) 38:35–42 47. Pessar L, Pristach C, Leonard K. What troubles clerks in psychiatry? A strategy to explore the question. Acad Psychiatry. 2008;32:194–8. 48. Brown T, Addie K, Eagles J. Recruitment into psychiatry: views of consultants in Scotland. Psychiatrist. 2007;31:411–3. 49. Lampe L, Coulston C, Walter G, Malhi G. Familiarity breeds respect: attitudes of medical students towards psychiatry following a clinical attachment. Australas Psychiatry. 2010;18:348–53. 50. El-Sayeh H, Budd S, Waller R, Holmes J. How to win the hearts and minds of students in psychiatry. Adv Psychiatr Treat. 2006;12:182–92. 51. Park R, Chibnall J, Morrow A. Relationship of rotation timing to pattern of clerkship performance in psychiatry. Acad Psychiatry. 2005;29:267–73. 52. Serby M, Schmeidler J, Smith J. Length of psychiatry clerkships recent changes and the relationship to recruitment. Acad Psychiatry. 2002;26:102–4. 53. Oakley C, Oyebode F. Medical students' views about an undergraduate curriculum in psychiatry before and after clinical placements. BMC Med Ed 2008;8:26 54. Brenner A. What medical students say about psychiatry: results of a reflection exercise. Acad Psychiatry. 2011;35:196–8. 55. Roberts L, Bandstra B. Addressing stigma to strengthen psychiatric education. Acad Psychiatry 2012;36:347-50 56. Lyons Z, Power B, Bilyk N, Lofchy J, Claassen J. Evaluation of the Claassen Institute of Psychiatry for Medical Students. Australas Psychiatry. 2010;18:12–6. 57. Manassis K, Katz M, Lofchy J, Wiesenthal S. Choosing a career in psychiatry: influential factors within a medical school program. Acad Psychiatry. 2006;30:325–9.
